Evidence vs. Alternative Facts

By David K. Jones, Editor-in-Chief, Public Health Post

February 10, 2017

News

Let’s be honest – every president is selective about which truths they highlight. But the level of misrepresentation by the Trump administration in its first month far exceeds anything we have seen before. If we can’t trust Kellyanne Conway and Sean Spicer on crowd sizes how can we take anything they say about policy seriously? The debate over health reform is so complex that the average American will not be able to sift through their statements to decide for themselves what is true and what isn’t. A recent survey showing that 1 in 3 Americans do not know that Obamacare is the same thing as the Affordable Care Act epitomizes the challenge of having an informed debate about health reform.

Evidence on a Postcard

A friend of mine recently hosted a party in which guests wrote facts about the ACA, the immigration executive order, and climate change on the back of 800 postcards. The postcards were then sent to someone in Wisconsin who mailed them to Speaker Paul Ryan from a post office in his district. My friend even went through the trouble of specially ordering Wisconsin postcards with pictures of cows and cheese on the front.

This is a creative act of protest reminiscent of some of the most effective actions undertaken by the Tea Party. In late 2011, Wisconsin Governor Scott Walker was under enormous pressure to return a federal grant his administration had received to create a health insurance exchange as part of implementing Obamacare. Activists mailed him hundreds of envelopes filled with strings to symbolize the dangerous strings they believed were attached with grant money from the Obama administration. Activists also collected enough signatures to trigger a recall election, forcing him to campaign again just two years after winning office. Within two days of these signatures being submitted, Governor Walker announced he was returning the grant money.

There is some evidence that Republicans in Congress are getting nervous about the level of engagement they are seeing from ACA supporters. Leaked audio from the recent Republican retreat makes it clear that there is not yet consensus on what to replace the ACA with if it is repealed. In fact, Republicans are starting to talk more now about “repairing” the ACA rather than repealing or replacing it. The most recent ideas floated by the Trump administration include fairly modest changes such as increasing the ratio between what insurance companies can charge older and younger enrollees from 3:1 to 3.49:1.

My friend asked me to provide a short list of facts about the ACA that guests at her party could put on the back of the postcards they mail to Speaker Ryan. I unfortunately could not respond in time to help her, but below is a list of short talking points about what I would have said.

Here is the best and most recent evidence we have about the ACA

1) The ACA has without question reduced the number of people without health insurance. The exact number depends on how you count the uninsured, but by every measure the number has dropped dramatically since the ACA fully went into effect in 2014. According to Gallup, 17.1% of U.S. adults lacked insurance at the end of 2013. By the end of 2015 this was down to 11.9% and in 2016 this dropped to 10.9%. The CDC estimated that the uninsured rate dropped to around 9% in early 2016. These are dramatic and unprecedented changes affecting millions of people. The changes vary dramatically throughout the country depending on choices made by individual states, with the uninsured rate remaining very high in many states that have resisted the ACA.

4) Donald Trump’s campaign proposals to repeal and replace the ACA (to the extent there was one) would be costly and result in millions losing coverage. He has since promised that everyone would be covered with lower premiums and deductibles. He hasn’t said how he would do that either, but Trump’s campaign plan costs $550 billion over 10 years and results in 21 million more uninsured.

5) One of the biggest criticisms against Obamacare recently was the 25% average premium increase for exchange plans. This is alarming if the trend continues, but should be placed in context. Analysis by Loren Adler and Paul Ginsburg at Brookings shows that premiums are lower than we expected them to be at this point and lower than they would be without Obamacare. Don’t forget to factor in the tax credits. Most consumers experienced a change of 0% in the premium they paid for 2017 compared to year before.

6) There is a low level of competition in some state exchanges. In many states there is only one insurance company selling plans. This undermines the whole premise of an exchange that competition will benefit consumers by driving down prices. I have written before about why this criticism is somewhat disingenuous, but this is nevertheless an important issue that needs addressing.

7) ACA plans provide good coverage. Plans sold on the exchange are more comprehensive than what most people in the individual market would have been able to purchase otherwise. But there is a worrisome trend towards increasingly high deductibles. One analysis suggests that 90% of enrollees in exchange plans have deductibles greater than $1,300 for an individual and $2,600 for a family. The ACA has cost-sharing reductions to mitigate this problem, but there is still a significant burden on low-income populations.

8) Hospitals spend $7.4 billion less on uncompensated care because more people have insurance. The drop is estimated at $5 billion in states that expanded Medicaid and $2.4 billion instates that did not.

10) The effects of the ACA on businesses is complex, but most businesses have not dropped employer-sponsored coverage as predicted. Many employers dislike or are apprehensive about the ACA, but more than anything they want stability.

The law is not perfect. Changes need to be made. But as political scientist Frank Thompson has written, the right criteria for evaluating reforms is not whether they solve all problems, but whether they leave us with a better set of problems than we would otherwise have. The ACA passes that test.

David K. Jones is Assistant Professor in the Department of Health Law, Policy and Management at the Boston University School of Public Health, and editor-in-chief of Public Health Post from 2016-17. His research examines the politics of health policy. He has written about health insurance exchanges, Medicaid, CHIP, and the social determinants of health.